摘要：Broad recognition now exists that price, availability, and other structural factors are meaningful barriers to fruit and vegetable consumption, particularly among low-income adults. Beginning in 2005, the New York City Department of Health and Mental Hygiene used the social–ecological model to develop a multifaceted effort to increase fruit and vegetable access citywide, with emphasis in low-income neighborhoods. Overall, the percentage of New York City adults who reported consuming no fruits and vegetables in the previous day decreased slightly over a 10-year period (2002: 14.3% [95% confidence interval = 13.4%, 15.2%]; 2012: 12.5% [95% confidence interval = 11.4%, 13.6%]; P for trend < .001). Our approach hypothesizes that complementary initiatives, implemented simultaneously, will create a citywide food environment that fuels changes in social norms and cultural preferences, increases consumer demand, and supports sustainable access to affordable produce. Fruit and vegetable consumption is recommended by the American Heart Association and others as part of a healthy diet and specifically for reducing cardiovascular disease, the leading cause of morbidity and mortality in the United States. 1–3 However, broad recognition now exists that price, availability, and other structural factors are meaningful barriers to fruit and vegetable consumption in the general population, and particularly among low-income adults. 4,5 Previously published studies have documented disparities in access to healthy foods, with the most limited access being observed in neighborhoods of high poverty and high minority composition. 5–7 In a systematic review of environmental determinants of fruit and vegetable consumption among adults, in which environment was defined as “all factors external to the individual,” household income was shown to be the most widely studied variable and also highly predictive of fruit and vegetable consumption. 4 More recent studies have corroborated these findings, demonstrating that healthier diets, which include higher produce consumption, are more expensive, and that price is a meaningful barrier. 8–12 When price is reduced by using coupons and discounts as incentives to buy more fruits and vegetables, purchasing is increased. 13,14 In addition, individual-level factors, including limited cooking skills and lack of familiarity with a variety of fruits and vegetables, may influence food choices. 15,16 In sum, addressing both availability and income, as well as other barriers, such as lack of food preparation knowledge, should be considered in the development of broader strategies to increase fruit and vegetable consumption in diverse urban communities. On the basis of these findings, federal, state, and local efforts to increase access to fresh produce have increased substantially over the past decade. In addition to federal grant funding via the Centers for Disease Control and Prevention’s (CDC’s) Communities Putting Prevention to Work program and other initiatives, the Healthy Food Financing Initiative was introduced at the federal level to provide funding for locally based initiatives focused on increasing access to fresh produce and other healthy foods for low-income families. 17,18 In the 2014 reauthorization of the Farm Bill, increased funding has been made available for the Healthy Food Financing Initiative, along with a number of other initiatives focused on improving access to fresh produce for low-income Americans, including the Farmers' Market and Local Food Promotion Program, Community Food Projects, Specialty Crop Block Grants, the Senior Farmers' Market Nutrition Program, and Beginning Farmers. 19 The Healthy Food Financing Initiative support has focused on food deserts—areas that lack full-service grocery stores—and has funded farmers’ market initiatives, urban farms, construction of new supermarkets and other retail outlets, and renovation of existing markets throughout the nation. 20 In addition, state agencies have partnered with their municipal counterparts, as well as community-based organizations (CBOs), faith-based organizations, and others, to improve access to fruits and vegetables for low-income adults. Incentive and voucher programs at farmers’ markets have provided additional dollars to shoppers for the purchase of fresh produce (often a dollar-for-dollar match, or $2 for every $5 spent). 21,22 Furthermore, initiatives such as the Healthy Corner Stores network, a coalition of organizations that supports efforts to improve availability of sales of healthy, affordable foods through small-scale stores in underserved communities, have also improved access to fruit and vegetables at the neighborhood level. 23 Despite these promising efforts, local programs are often limited in scale and scope, and implemented in isolation from other initiatives. To develop a comprehensive approach to improve access to fresh produce in a large metropolitan area, the New York City Department of Health and Mental Hygiene (DOHMH) used the social–ecological model as a framework to design and launch a series of complementary initiatives, with the goal of reducing disparities in access and achieving similarly high produce purchasing and consumption of fruits and vegetables across all population groups. With this framework in mind, citywide efforts have been complemented by programming for those at highest risk for diet-related diseases, including type 2 diabetes and cardiovascular diseases, in high-poverty neighborhoods, including the South Bronx, East/Central Harlem in Manhattan, and North/Central Brooklyn, where the DOHMH’s 3 District Public Health Offices are located ( Figure 1 ). Open in a separate window FIGURE 1— Neighborhoods of focus for the District Public Health Offices (DPHO) of New York City Department of Health and Mental Hygiene. aOnly a small area of the zip code lies within the focus community districts. Although included in the District Public Health Office focus area for outreach and programming, such zip codes are not generally included when calculating area-level rates of illness. Beginning in 2005, the New York City DOHMH developed collaborative partnerships with governmental agencies and CBOs to introduce a social–ecological approach to health, relying on the social–ecological model to guide program development intended to increase access to fruits and vegetables citywide. The social–ecological model, which recognizes that individuals are embedded within larger social systems, is used by the CDC and others to understand and address challenges to population health. Initiatives are introduced at multiple levels of human behavior—societal, community, institutional, interpersonal, and individual—to effect change. 24 In this article, we summarize the key components of the DOHMH’s approach and the results achieved, which may serve as an example for other jurisdictions seeking to increase fruit and vegetable access to improve population health through a comprehensive approach.
